The Quality and Outcomes Framework – transforming the face of Primary Care in

the UKSteve Gillam, University of Cambridge

A Niroshan Siriwardena, University of Lincoln

Background

Introduced in 2004 in the UK

>£1billion per annum

22% GP income

Largest natural experiment in pay for performance (P4P) in the world

Precursor schemes, e.g. PRICCE

Domains for quality indicators in QOF 2009

Clinical Secondary prevention of coronary heart

disease Cardiovascular disease: primary

prevention Heart failure Stroke & TIA Hypertension Diabetes mellitus COPD Epilepsy Hypothyroid Cancer Palliative care Mental health Asthma Dementia Depression Chronic kidney disease Atrial fibrillation Obesity Learning disabilities Smoking

Organisational Records and information Information for patients Education and training Practice management Medicines management

Patient experience Length of consultations Patient survey (access)

Additional services Cervical screening Child health surveillance Maternity services Contraception

Methods

Secondary analysis of research including quasi-systematic review

Medline, EMBASE, CINAHL, PsycINFO, Health Business Elite, Health Management Information Consortium, British Nursing Index, Econ Lit to January 2010

45 research papers

Results

Health care gains Effects on population health and equity Costs and cost effectiveness Impact on providers and team climate Patients’ experience and views

Health gains Real but modest gains in some areas, e.g. asthma, diabetes No definite improvement in CHD related to QOF Better recording in QOF but not untargeted areas No improvement in outcomes, except epilepsy

N Engl J Med 2009;361:368-78.

Population health and equity Inequalities related to deprivation slowly narrowing

Reductions in age-related differences for CVD/diabetes

Variable effects for e.g. gender related differences in CHD

Dixon, Khachatryan & Boyce. The public health impact, In Gillam & Siriwardena (eds) The Quality and Outcomes Framework, Radcliffe, Oxford 2010.

Lancet 2008; 372: 728–36

Cost effectiveness

No relationship between pay and health gain Cost effectiveness evidence for 12 indicators in the 2006

revised contract with direct therapeutic effect 3 most cost-effective indicators were:

ACEI/ARB for CKD Anticoagulants for AF and Beta-blockers for CHD

Team working Changing structures, roles and staff – nurse-led care

Greater use of information technology

Restratification: ‘chasers’ and ‘chased’

Emphasis on the biomedical

Commodification of care

Narrative of ‘no change’

Checkland & Harrison. Impact of QOF on practice organisation and service delivery.

Patient experience Little research on patient related/reported impact

Continuity and relationship affected

Fragmentation of care

Little explanation provided to patients

Wilkie. Does the patient always benefit? In…

“A slim, active 69-year-old patient attending for influenza vaccine was faced with questions about diet, smoking, exercise and alcohol consumption. There was no explanation for why these questions were asked; they seemed irrelevant to havinga ‘flu vaccine. Blood pressure and weight had to be recorded and a cholesterol test organised. A short appointment lasted almost 15 minutes without the patient having the opportunity to ask a question about any aspect of ‘flu vaccine.”

Discussion and debate Improved data recording and analysis

Modest health benefits for individuals and populations

Narrowing of inequalities in processes of health care

Opportunity costs contested

Unintended consequences: on workforce, professionalism

Negative effect on care: ‘McDonaldisation’

Re-defined meaning of quality

Conclusions and ways forward Leave indicators unchanged and anticipate higher

achievement each year

Add new indicators or conditions

Select from a larger set of evidence-based measures

Remove measures once agreed level achieved

Rotate measures

New Coalition government has other plans…